Treat-to-Target Strategy Works Well for Psoriatic Arthritis

Aggressive treatment addresses many symptoms of the disease and results in better outcomes.

October 28, 2013 | By Alice Goodman

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People with psoriatic arthritis (PsA) who are treated according to an aggressive and strict protocol called “treat to target,” or T2T, have better control of their disease than those who received standard care, according to recent research.

Psoriatic arthritis is a form of inflammatory arthritis that affects an estimated 30 percent of people with the skin condition psoriasis (marked by red, scaly, painful rashes). PsA can lead to pain, inflammation and, potentially, joint damage.

T2T is a strategy now regularly used in treating patients with rheumatoid arthritis. It means when disease begins or is first diagnosed, a rheumatologist and patient set a specific target or goal – like a very low level of inflammation. Patients are then monitored with that target in mind and if they aren’t making good progress towards the goal, treatment is changed and often intensified to help them get there.

“The treat to target strategy concept is to achieve low or no disease activity. The background is that improved control can result in improved long-term outcomes, better quality of life and improved health compared with poor disease control,” explains Eric Matteson, MD, chair of the division of rheumatology at Mayo Clinic in Rochester, Minnesota.

Treat to Target Reduces Pain and Inflammation

The first study to evaluate a treat-to­-target (T2T) strategy in psoriatic arthritis patients was conducted by Laura C. Coates, MD, a lecturer at the University of Leeds in the United Kingdom. The results of the study were presented at the American College of Rheumatology’s annual meeting in San Diego in 2013.

Dr. Coates’ study included 206 patients who had symptoms of PsA for less than two years and had not previously received disease modifying antirheumatic drugs (DMARDs), such as methotrexate or leflunomide. The group was randomized to T2T or standard therapy.

Patients in the T2T group received methotrexate and were assessed every four weeks. They were asked about pain, disease activity and ability to perform daily tasks. They also were assessed for tender and swollen joints, enthesitis (inflammation where tendons or ligaments insert into bone), and whether skin psoriasis was active.

Those who did not achieve minimal or no disease activity after 12 weeks were stepped up to additional DMARDs (combination therapy). If, after another 12 weeks, they still had not reached the target of minimal or no disease activity, they were either given a biologic drug or switched to another DMARD with methotrexate.

By contrast, patients in the standard care group were put on DMARDs but not treated according to any escalation plan, schedule or target; treatment was up to the individual doctor.

After 48 weeks, patients in the T2T group were almost twice as likely to have their symptoms improve by 20 percent compared to the standard care group, and about 2.5 times more likely to have a 50 percent or a 70 percent improvement in the signs and symptoms of PsA compared with the standard care group.

“The study confirmed that treating to a specific target can improve clinical outcomes for patients with psoriatic arthritis. Tight control led to a significant improvement in outcomes for both arthritis and skin psoriasis,” she explained.

Treat to Target Works for a Variety of Symptoms

Another benefit of the T2T approach is that it worked for patients with different aspects of PsA. “The target used in the study – minimal disease activity – assesses a wide spectrum of disease features, including skin and enthesitis, and not just the articular [joint] aspects of this complex disease,” notes study co-author Philip Helliwell, MD, senior lecturer in rheumatology at the University of Leeds. “Patients with this disorder have to endure several different disease manifestations.”

Although patients in the T2T group used biologic therapy more frequently than patients in the standard care group, the use of methotrexate and corticosteroids was similar in both groups, Dr. Coates says. She adds that the T2T group had more side effects, but the majority of patients tolerated treatment well.

Treat to Target Relies on Doctor–Patient Partnership

In a review of available research published in Current Opinion Rheumatology in 2015, Dr. Coates said it seems T2T works because “ongoing joint inflammation predicts subsequent damage and loss of function.” She says the strategy has shown “significant benefit in joint and skin disease activity and patient-reported outcomes.”